What is the cause and treatment for unilateral hip pain that worsens upon waking?

Unilateral Hip Pain Worse Upon Waking: Diagnosis and Treatment

Your unilateral hip pain that worsens upon waking most likely represents either osteoarthritis, greater trochanteric pain syndrome (trochanteric bursitis/gluteus medius tendinopathy), or an intra-articular problem like a labral tear or femoroacetabular impingement, and you should start with plain radiographs of the pelvis and hip as your first diagnostic test. 1

Initial Diagnostic Approach

Start with plain radiographs (AP pelvis and frog-leg lateral hip view) as your first imaging test. 1 This is the recommended initial screening tool that can identify:

• Osteoarthritis (most common in adults) 1
• Bone tumors 1
• Dysplasia or femoroacetabular impingement 1
• Fractures 1

For osteoarthritis specifically, physical examination combined with radiography has reasonable sensitivity and specificity and may be better than MRI for diagnosis. 1

If Radiographs Are Negative or Equivocal

Proceed to MRI without IV contrast as the next imaging study. 1 MRI is both highly sensitive and specific for detecting soft tissue and osseous abnormalities and should be the first imaging technique after radiographs. 1

MRI can identify:

• Soft tissue causes: Trochanteric bursitis, gluteus medius tendinopathy or tears, iliopsoas bursitis, calcific tendonitis 1
• Intra-articular causes: Labral tears, femoroacetabular impingement, cartilage damage 1
• Referred pain sources: Lumbar spine pathology, sacroiliac joint issues 1, 2

Treatment Based on Diagnosis

For Osteoarthritis (If Confirmed):

Initial treatment should include:

1. Self-management program with regular exercise and weight reduction if applicable 1
2. Topical NSAIDs for knee OA or oral NSAIDs/acetaminophen for hip OA 1
3. Physical therapy referral based on pain severity and functional limitations 1

Second-line pharmacotherapy options:

• Duloxetine 30-60 mg daily (taken daily, not as needed) for pain management 1
• Intra-articular corticosteroid injection (must be image-guided for the hip) 1
• Avoid opioids including tramadol due to limited benefit and high risk of adverse effects 1

For Soft Tissue Causes (Trochanteric Bursitis/Tendinopathy):

Ultrasound-guided diagnostic and therapeutic injections can confirm the pain location and provide short-term relief. 1 Trochanteric bursal or peritendinous injections are useful for both diagnosis and treatment. 1

For Intra-articular Pathology (Labral Tears/Impingement):

Consider MR arthrography or high-resolution 3T MRI if labral tear is suspected and initial MRI is inconclusive. 1 Direct MR arthrography with intra-articular gadolinium is the established technique for diagnosing acetabular labral tears. 1

Diagnostic intra-articular anesthetic injection can confirm if pain originates from within the joint. 1 If positive and conservative treatment fails, arthroscopic surgery typically has good outcomes for femoroacetabular impingement and labral tears. 2, 3

Critical Pitfalls to Avoid

• Don't skip radiographs: Even if you suspect soft tissue pathology, radiographs should be obtained first to rule out serious bony pathology like tumors or fractures 1
• Don't use opioids for osteoarthritis pain: They show limited benefit with high adverse event rates and withdrawal symptoms 1
• Don't perform hip corticosteroid injections without image guidance: Hip injections should always be image-guided 1
• Don't ignore referred pain: Hip pain can originate from the lumbar spine, sacroiliac joint, or knee 1, 2, 4

When Morning Stiffness Is Prominent

Morning stiffness that improves with activity suggests inflammatory arthritis or osteoarthritis. 1 If osteoarthritis is confirmed, the treatment algorithm above applies. If radiographs suggest inflammatory arthritis, rheumatologic evaluation with blood work may be appropriate. 1